ARTICLE OF THE MONTH
Perinatal mental health and wellbeing: policy and practice
In the first article of our new series on perinatal mental health, we provide an overview of the relevant policy landscape in England. Future papers in this series will include a discussion on pathways for mothers affected by more severe mental health conditions; information provision and tools; fathers; and a review of a creative engagement exercise carried out in South London.
Midwife and Researcher at the Polyanna Project, London
Consultant Midwife (public health) at Barking, Havering and Redbridge University Hospitals NHS Trust
This new series stresses the importance of perinatal mental health and wellbeing. Policy and guidelines have been written to help support midwives in delivering care so that a woman’s mental health is treated as comparable with their physical health. There are key messages and recommendations within the policy and guidance that, when followed can, not only reduce the unnecessary suffering that many women and families face but also help limit perinatal morbidity and mortality.
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Mental health, is defined by the World Health Organization (WHO) as “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (2014: 1).
Government policy (Department of Health [DH] 2011; Maternity Safety Programme Team [MSPT] DH 2016; Leadsom et al 2014) and guidance (National Institute for Health and Care Excellence [NICE] 2014) recognises the equal status and importance that midwives must place on identifying and caring for women’s mental health alongside their physical wellbeing during the perinatal period. Meeting the needs of parents with suboptimal mental health is ingrained in The Code (Nursing and Midwifery Council [NMC] 2015: 7): “Maintain the knowledge and skills you need for safe and effective practice”. Perinatal mental wellbeing and health is one area where midwives need to demonstrate their professionalism by “incorporating up-to-date evidence in daily practice” (NMC 2017: 5), as outlined in this article, and in so doing “Enable person-centred and evidence-informed practice” (NMC 2017: 6).
Mental wellbeing can be described as a “positive state of mind and body, feeling safe and able to cope, with a sense of connection with people, communities and the wider environment” (DH 2011: 90).
Nationally, 10-15 per cent of women experience anxiety and/or depression in pregnancy and up to 20 per cent in the first year after childbirth (Bauer et al 2011; Khan 2015; NICE 2014). Maternal mental health conditions range on a continuum from low mood to psychosis (Russell 2017). The MBRRACE-UK report Saving lives, improving mothers’ care (Knight et al 2014) identified that 25 per cent of all maternal deaths between six weeks and one year after childbirth were related to mental health problems and that one in seven of these women died as a result of suicide. Research demonstrates that poor mental health and wellbeing has a major impact on not only the immediacy of the mother-baby relationship but also subsequent long term, physical, emotional and cognitive development for the child (Bauer et al 2014; Barker et al 2011; Talge et al 2007)
The Maternal Mental Health Alliance (MMHA) (a coalition of over 80 professionals) has a core ideal to make maternal mental health equal to physical health: poorly managed perinatal mental health can adversely affect maternal self esteem, relationships within the family, both with the partner and wider family including children. If a mother experiences anxiety or depression while pregnant, her child has double the risk of probable mental health disorder by the age of 13 (Shakespeare 2014: 2).
However, treatment and support for mental health by the maternity and wider healthcare team can only be improved if the issues around identification, such as giving women ‘time to talk’ and a reduction in the fear and stigma associated with emotional or mental health problems, are addressed. The policy and guidance outlined in this article support midwives in delivering high quality care for all women who use maternity services in England.
PERINATAL MENTAL HEALTH POLICY
Embedded in the succession of government policies over the last decade has been a steady growth of improvements in identification and care pathways for people suffering suboptimal mental health. With the energy and dynamism of the MMHA, mental wellbeing has been highlighted within the perinatal period, raising the importance of this issue up the political ladder. In 2014 the policy document Closing the gap (DH 2014) led to an increase in access to psychological services through midwives’, health visitors’ and General Practitioners’ (GPs) training programmes, leading to increased awareness.
The cross-parliamentary manifesto: The 1001 critical days (Leadsom et al 2014), lists a number of recommendations and specifically calls for:
More recently, the above concepts have been further endorsed and given momentum by NHS England (NHSE) in the national maternity review, Better births (NHSE 2016) and Safer maternity care (MSPT DH 2016). With the aspiration of offering more personalised and safer care, Better births explicitly cites synergising with the NICE (2014) recommendations to improve the identification of mental wellbeing, access to services, multidisciplinary working and education in perinatal mental health.
Policy direction aims to improve the experience of women and their families so that they are central to services, receive the care they need, delivered in a seamless way with improved multi-professional communication. Better births (NHSE 2016) advocates the concept of ‘Hubs’ – ‘one-stop shops’ where women, their babies and families can receive fast effective referrals and the treatment they need (MSPT DH 2016; NHSE 2016). Currently where you live affects access to acute perinatal mental health services; in some areas there is no specialist service (NHSE 2016). Other areas, such as north-east London, Hampshire, East Midlands and Bristol, have developed examples of excellent perinatal mental health services (shown in Table 1). The vision for the future is to ‘iron out’ the geographical inconsistencies in mental health care for pregnant and postnatal women. NHS England, the Maternity Transformation Programme and the Mental Health Transformation Board are currently working collaboratively to produce care pathways and protocols for specialist community perinatal mental health services (Russell 2017). Their key priorities for perinatal mental health for women using maternity services are that:
Table 1. Examples of established perinatal mental health services in England
PERINATAL MENTAL HEALTH GUIDANCE
The NICE guidance (2014) reiterates the importance of the woman’s journey through pregnancy into motherhood as an ideal opportunity to assess mental health and wellbeing. The booking appointment is crucial as an initial opportunity for the midwife to make the first assessment. The booking is best understood as a holistic, needs, risk and choice assessment, in order to plan ongoing care for women’s physical and mental wellbeing. The main areas recommended by NICE (2014) for midwives to assess wellbeing and mental health in pregnancy and the postnatal period are:
The booking is an initial assessment only; as the mother progresses through her pregnancy and into motherhood, her needs, risks and choices should be continually reviewed and, where necessary, modified.
NICE (2014) recommends that women are also asked the Whooley, Arroll and ‘generalised anxiety disorder’ questions (GAD) as part of the booking assessment (see Box 1).
Box 1. Screening questions for identification of perinatal mental health concerns
1. The Whooley questions:
During the past month, have you often been bothered by feeling down, depressed or hopeless?
During the past month, have you been bothered by having little interest or pleasure in doing things? (NICE 2014: 11).
2. The ‘help’ question:
Is this something you need/want help with? (Arroll et al 2003)
3. The GAD scale:
During the past month, have you often been feeling nervous, anxious or on edge?
During the past month have you not been able to stop or control worrying (NICE 2014: 11)?
NICE advocates that these enquiries are posed again in the early postnatal period and that all providers of care consider asking women at every contact throughout her pathway through pregnancy, birth and the postnatal period (up to one year).
If a woman’s response is affirmative to the Whooley questions (in Box 1), this indicates she could be at risk of developing a mental health problem and it is recommended that there is further exploration of mental wellbeing through services such as Improving Access to Psychological Therapies (IAPT), health visiting or general practitioners (NICE 2014). A recent report, The hidden half (NCT 2017) argues that getting support and treatment early, such as GP support, peer support, counselling or medication, can make a difference between mothers being able to enjoy their new baby and deteriorating further with the risk of becoming seriously unwell.
The policy and guidance discussed in this paper stand as a ‘backbone’ for midwives’ practice. It is imperative that midwives effectively identify and offer referral and support to pregnant women and mothers in a timely way. Following these policy recommendations has the potential to positively affect the mother, her baby and her immediate family. Midwives are pivotal in supporting women’s emotional wellbeing, in the perinatal period, giving it parity of importance with physical health.
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Talge NM, Neal C and Glover V (2007). ‘Antenatal maternal stress and long-term effects on child neurodevelopment: how and why?’ Journal of Child Psychology and Psychiatry, 48(3-4): 245-261.
WHO (2014). Mental health a state of wellbeing, Geneva: WHO. www.who.int/features/factfiles/ mental_health/en/
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